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How Formerly Independent Doctors Were Pushed Out of Business

Rules and regulations intended to reform health care are driving private practices out of business by overconfident design.

zerocreatives/Westend61 GmbH/Newscomzerocreatives/Westend61 GmbH/NewscomLike many American physicians, my wife no longer works for herself. Under the same pressures that have forced many once-independent practices to consolidate, she was lucky enough to find a large health-care organization willing to purchase her practice and ensure continuity of care for her patients. "Is the independent doctor disappearing?" U.S. News & World Report asked earlier this summer. The answer is: yes—and to a significant extent, that's a result of deliberate policy.

Your doctors didn't jump out of business; they were pushed. And they were pushed by people way too convinced of their qualifications to redesign the world around them.

Just 33 percent of physicians "identify as independent practice owners or partners," the Physicians Foundation reported in its last last survey, conducted in 2016. That's down from 48.5 percent in 2012.

But while a majority of doctors now opt to work as employees, "most physicians, even many who are themselves employed by hospitals, do not believe hospital employment of physicians is a positive trend," the foundation reported. So, why are doctors going to work for large organizations when they seem so resistant to the idea?

Factors including "government insurance mandates and changes to health insurance design to new reporting requirements, escalating costs and the rise of urgent care clinics" feature in the U.S. News article, which also notes that "Unique for physicians are certain requirements surrounding electronic health records and new reporting requirements regarding patient visits as part of the Affordable Care Act."

"The factor cited most frequently by physicians as being least satisfying is 'regulatory/paperwork burdens' followed by 'erosion of clinical autonomy,'" the Physicians Foundation survey notes. "Medicare compliance rules and regulations alone running into the tens of thousands of pages" in addition to the miles of red tape contained in the Affordable Care Act.

The regulatory squeeze pushes doctors to sell their practices and consolidate compliance. And while a lot of pressures have simply accumulated over decades, that transformation is partially as intended.

"To realize the full benefits of the Affordable Care Act, physicians will need to embrace rather than resist change," Obama administration health care advisers, Nancy-Ann DeParle, Ezekiel Emanuel (brother of Rahm), and Robert Kocher wrote in a letter published by the Annals of Internal Medicine in 2010. "The economic forces put in motion by the Act are likely to lead to vertical organization of providers and accelerate physician employment by hospitals and aggregation into larger physician groups."

After the letter "sparked controversy for daring to suggest that it's time for physicians to join larger groups," as CBS News put it, the language was apparently slightly revised. But the old wording is still widely available in news reports from that year. Even revised, the letter boasts that Affordable Care Act "reforms will unleash forces that favor integration across the continuum of care...Only hospitals or health plans can afford to make the necessary investments in information technology and management skills."

Let's consider those "necessary investments in information technology."

One of the letter's key assertions about "reforms" promoted by the government includes "expanding the use of electronic health records with capacity for drug reconciliation, guidelines, alerts, and other decision support." The idea was that digitizing patients' medical data was such a good idea that, despite being an expensive and complicated endeavor, doctors should be threatened with reduced Medicare and Medicaid payments if they refuse.

While the burdens of switching to electronic health records at government command have certainly been proven–"the challenges have proved daunting, with a potential for mix-ups and confusion that can be frustrating, costly and even dangerous," The New York Times reported—the benefits don't always materialize. Many different electronic health records systems can't even speak to one another, which would seem to eliminate a big advantage of having data in digital form.

Using electronic records cost physicians an average extra 48 minutes per day, according to a 2014 report. "Surprisingly, a third (33.9%) reported that it took longer to find and review medical record data" with electronic records management than without it.

Only 11 percent of physicians said electronic health records improved their interactions with patients, while 60 percent said they "detracted from patient interaction," the Physicians Foundation noted in 2016.

It's not that electronic records are inherently bad. But if physicians are adopting them only under protest, that's an indication that the technology may not yet be ready to be used in the real world. If vendors had needed to improve their products to tempt customers, they might well have created electronic health records systems that improved life for doctors and patients alike. Instead, doctors were ordered to pick among existing products, or else.

The failure of electronic health records systems to live up to predictions offers a key insight into the hubris of scolding doctors that they "need to embrace rather than resist change" and smugly announcing that your favored policies "will unleash forces that favor integration across the continuum of care." When one of your much ballyhooed "reforms" turns out to be prone to making life worse for those whose work has been reformed, maybe you need to rethink your grand scheme. It could be that the whole health-system-in-a-bottle envisioned by government experts works a lot better in theory than it does once foisted on actual human beings.

But don't look for policymakers to admit that their vision for how the world should work might not play out properly in real life. If they were inclined to concede that people might be better off when left alone to arrange their own affairs, they probably wouldn't be policymakers.

So, as you watch formerly independent physicians reluctantly close up shop and go to work for larger organizations, keep in mind that this transformation of health care is largely by overconfident design.

Photo Credit: zerocreatives/Westend61 GmbH/Newscom

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  • buybuydandavis||

    The medical mafia, after using the government to shake down consumers, now find that they are increasingly squeezed in their turn

    I don't weep for them, although I do weep for all the Americans whose lives will be shortened and made more sickly by the never ending march of apparatchik power now marching on the doctors.

  • geo1113||

    Medicare for all!!!!!!!!!!!!!!!!!!!

  • Horny Lizard||

    But abortion regulations are for safety!

  • NotAnotherSkippy||

    Just common sense controls. And why shouldn't we learn from our european betters?

  • sarcasmic||

    Independent doctors could much more easily resist single payer than doctors who are employees of hospitals.

    Must eliminate them before forcing single payer upon the population.

  • CatoTheChipper||

    ^THIS.

    Progressives favor large, centralized organizations rather than small, diffused ones. That makes the government's job of planning, regulating, and controlling such non-governmental organizations easier. The fact is that, despite their protests to the contrary, the actual policies of progressives lead (or would lead) to large banks, large corporations, large farms, large political parties, large unions, etc.

  • BYODB||

    Yes, and it's not a coincidence that essentially all the Doctor's of all stripes that I talk to who are independent are the most critical of those programs. Honestly, an independent Doctor is one of the bravest, dumbest sons of bitches left in this nation given the shit they must deal with under penalty of law.

    It's no wonder there are only around 250,000 of them in a nation of 320(ish) million souls, either. The more you regulate them, the fewer of them you'll have (and the more nurses, NP's, PA's etc. you'll see instead).

    You'll notice none of the people shilling for 'single payer' or the like ever mention supply, and it's not an accident.

  • DrZ||

    There is a movement of "Direct Primary Care" (DPC) physicians who are bravely going where no doctor as gone before, at least after the 1940s when the government interceded and excrement hit the fan. DPC seems to hold some promise, but even these doctors who are independent must fight off government regulation that gets in the way of doctors striving to make it on their own.

    So far, the anecdotes are favorable. Patients know their financial obligations ahead of time, doctors are making a living and medical services are of high quality.

    Leave it to governments to want to get into the middle of something good. If a superior solution in medicine were to ever come about, people might start asking why we need politician's dirty fingers in our medicine. This is bad news for politicians.

  • #||

    I'm worried DPC though is going to get crushed by the next lurch towards further healthcare nationalization. It may only survive as a very high need expensive luxury product in the way that elite private schools are - a service only for those willing and able to "double pay".

  • Jerryskids||

    "reforms will unleash forces that favor integration across the continuum of care...Only hospitals or health plans can afford to make the necessary investments in information technology and management skills."

    And that was the point. It's easier to micro-manage a handful of large organizations than a bunch of small ones. Restricting choice and imposing conformity is always to the government's advantage, they'd just as soon see all small businesses disappear. Small business owners tend to be dangerously independent and individualistic.

  • perlchpr||

    Neofeudalism. Everyone works for a couple of very large 'landowners'. In turn, the Kind manages the landowners.

  • perlchpr||

    King, damnit.

  • DrZ||

    But we know that Kings are kind, right? And, by extension, policymakers are kind.

    I don't think you made an error.

    Oh and aren't auto spell corrector he'll?

  • Ron||

    this is exactly what Hillary was referring to when she decried people trying to make a living as small enterprises. eliminate the independent and you can control them all

  • JWatts||

    "as part of the Affordable Care Act."

    This was a planned feature not an unintentional bug.

  • Juice||

    If you like your doctor, well, they'll be out of business soon.

  • TrickyVic (old school)||

    If you like your doctor, give it time, they will need to move in with you.

  • West Texas||

    Instead, doctors were ordered to pick among existing products, or else.

    -----------------

    This is a common refrain among "reformers" in government: ethanol mandates, backup cameras, smart guns, low flow showers.

    They think that the only reason these things haven't been adopted is due to stubbornness and resistance and not just good old fashioned what works best practicality.

    So we have to make them switch instead of letting the market organically improve on its own.

  • turco||

    He elided over one of the biggest drivers of doctor employment by hospitals. Medicare ( and commercial insurance which follows medicare ) pays much more if an outpatient encounter happens at a hospital facility compared to an independent doctor office . The medicare physician fee schedule includes two tables: facility and non-facility. If you have a procedure at a doctor who works on a hospital campus, the hospital bills medicare and the doctor bills medicare . If you do it in an independent doctor office, the doctor sends one bill to medicare. The extra money collected by the hospital can then be used to "reimburse" the doctor in indirect ways ( such as paying for their EMR and regulatory costs).

  • Bowfish||

    "Much more"?

    That's inverted. Doctors get paid LESS for doing the same work in hospitals because they only get paid primarily the work portion of the total RVU (This is the formula that's been "faulty" for years because of Congressional incompetence or design.) Your staff and supplies and tort risk are components of the total RVU that is considered only if the service is performed in your office.

    But it was sold to doctors as a "raise" when the concept was first introduced when in fact the fees for office based services remained largely the same; while the services for hospital based work were reduced.

    There also used to be codes for surgical trays and procedure rooms - which have been stricken from doctors in the office setting. Only hospitals and surgical facilities can use those codes with any expectation of being remunerated. That rate is "much more" than what office based doctors ever used to charge.

  • Horny Lizard||

    Dealing with the insurance companies is a big headache from what I hear. It's not always "govt bad", "private good". It's mostly people are stupid as shit and they're everywhere.

  • Azathoth!!||

    No, it's always "govt bad", "private good". The reason it's such a headache dealing with insurance companies is government interference.

    The endless problem of people who know what's better than the people who actually do the job.

  • FlyerJack||

    Always, huh? It must be so much easier when everything's black-and-white like that. Simple rules for simple minds...

  • epsilon given||

    Perhaps not literally "always" but a surprisingly large percentage of our health care system troubles are a result of government interference, either direct or indirect, compounded over decades of time.

    Typical modus operandi:

    1. Identify a problem. More often than not, the problem isn't really a problem, or is something imaginary.

    2. Propose a solution. It's designed by experts, but oddly enough, none of these "experts" have any experience or knowledge in the field they are trying to fix.

    3. Pass a law, and implement the solution.

    4. This solution will cause all sorts of problems, but that's ok, because we can blame the free market!

    5. Go to #2.

    A major source of headaches with health insurance -- where employer-provided insurance is pretty much the only decent way to get insurance, when properly it would be better if we provided our own insurance, independently of employers -- is the direct result of Government trying to cap wages, and employers needed a way to attract workers when they couldn't offer better salaries.

  • DrZ||

    You are on to something. Physicians who establish a Direct Primary Care business and cash-only surgical centers are proving that insurance and government add significantly to the cost of medicine. The estimates I have seen show that those who take cash end up being able to offer prices that are considerably less than if insurance companies and the government is involved not to mention hospitals who add to the overhead.

    These estimates indicate about 15-30% of today's costs are due to the overhead produced by insurance, government and hospital overhead.

    Doctors also end up with more time on their hands to interact with patients when they aren't spending time dealing with insurance companies, state and federal governments and hospitals.

  • Echospinner||

    Of course if you only take cash paying patients it is a great deal.

    Where do the others go? Eventually you are going to pay for them.

    Bowfish above talked about the real deal. The RVU and coding system drives everything. Take all patients and know that it is all cost shifting if you are hospital based. Take a pathologist or hospitalist for example. They do not choose anything. They have to take every patient and are only paid for the report or consult. Technical fees all go the hospital.

  • Unicorn Abattoir||

    Many of the problems with insurance companies are a result of the government's interference with them.

  • Tionico||

    You fail to realise that FedGov now mandates all manner and kind of record producing and managing even for people who do not pay via any insurance policy. IF a given entity accepts medicare or OhBummerTax for ANY patients, then all the Fed mandated record charade is REQUIRED for ALL patient encounters. So yes, the problem IS FedGov mandating all the useless busywork record making and keeping.

  • Bowfish||

    Perhaps you are correct. From my perspective health insurers are coerced by government to act as commodities rather than insurers. Most people understand that car and home insurance is for catastrophes. the maintenance is at your own expense because both car and home are investments.

    But when it comes to investing in your health, most people think their insurance should cover everything including cutting nails. Insurers, trying to create ways to get the patient's skin in the game, create complicated copay, deductible, and coinsurance schemes ostensibly to encourage patients to consider the cost v. benefit of intervention. Thereby exercising some utilization control. Alas, it's too confusing and patients take it our on their doctor, hospital or insurer.

    People who are for universal coverage are unaware of the costs, and of the eventual rationing.

  • Peacedog||

    Which is why one category of primary care doctors working in private practice is in fact growing: doctors who don't take insurance.

    I've met two in my area and they are some of the happiest people I know. They see roughly half the number of patients they did as slaves to the insurance system, which the medical association hates, but the patient pays their fee and they get either a full 30 or 60 minutes to talk to their doctor.

    Labs and services are outsourced with the doctor providing medical billing for the patient who then submits to their own insurance directly.

    Both of them said it was like waking up from a bad dream and being able to practice medicine again.

  • JFree||

    If we actually had near enough primary care doctors (which I'll arbitrarily define as pediatricians, GP's, geriatricians) - this could be a very positive move towards fixing our broken system. PCP's are the core of any health system that bases itself on the 80+% of the population that is generally healthy-enough - and in most places they can easily form into either independent practices or small-group practices (say the PCP's above plus an internal, OBGYN, NP) or other stuff that doesn't require the massive overhead of hospitals when hospital care isn't needed.

    Unfortunately, the American system has been built since 1910 or so (Flexner Report), on eliminating or minimizing the role of the GP. So we don't have nearly enough GP's to serve that 80% (roughly 1/3 of the number per capita as any other moderately wealthy country). So the more that go into concierge practice here, the more it will just create a two-tier system here. Where the lack of a trusted gatekeeper for most people will drive insurance costs even higher and make insurance even more bureaucratic.

  • Ron||

    the only problem is many hospital refuse to work with these new independent doctors. and Hospitals is where the surgery is done in major cases and you end up working with the hospitals doctor who is to busy to know your history or even care or doesn't care because of your independent doctor. My father has had this happen to him with his independent doctor

  • loveconstitution1789||

    Domestic trade restrictions kill businesses by the millions.

  • Stilgar||

    This trend has been going on for a long time now. Rent, insurance and admin costs prior to Obama care had pushed many in my area (a major metro region) into the grasps of the mega-med-center-corp. My own doc, who had been independent for nearly 30 years apologized when he finally caved and openly acknoledges that most of his patients hate the group he is with.

  • Cynical Asshole||

    "To realize the full benefits of the Affordable Care Act, physicians will need to embrace rather than resist change," Obama administration health care advisers, Nancy-Ann DeParle, Ezekiel Emanuel (brother of Rahm), and Robert Kocher wrote in a letter published by the Annals of Internal Medicine in 2010.

    "We are Top. Men. We know what's best for all! Now submit, proles!"

    Christ, what a bunch of smug assholes.

  • Griffin3||

    Using electronic records cost physicians an average extra 48 minutes per day

    I call hot, screaming bullshit on this. I do no know a single doctor who does not spend an entire 1/3 of the day, or longer, on extra electronic records bullshit. You could say, well, they still had to keep records, but the difference between dictating a note after each patient (which was offloaded to a paid transcriptionist), and the doctor filling out piles of medically related nonsense and checklists, in poorly written EHR programs, and it all has to be done by the doctor, is logged and verified and coded in ridiculous ways ... the extra time is often LONGER than the patient-doctor interaction.

    Only 11 percent of physicians said electronic health records improved their interactions with patients, while 60 percent said they "detracted from patient interaction," the Physicians Foundation noted in 2016.

    The 11% who noted improvement, were probably specialists with such light case loads it didn't even matter in the first place. Or these new students that keep rotating through, that spend half their time on the cell phones looking up symptoms anyway.

  • JunkScienceIsJunk||

    I call hot, screaming bullshit on this. I do no know a single doctor who does not spend an entire 1/3 of the day, or longer, on extra electronic records bullshit.

    You are absolutely correct. Their staff do the majority of this. I bet the study they're citing is an "hour-per-physician" number which does not imply that physicians do it.

    Or these new students that keep rotating through, that spend half their time on the cell phones looking up symptoms anyway.

    You'd be surprised how computer illiterate many of them are. 90% of the residents I deal with are 30 yo or younger, and I'd say a solid 50% of them have trouble understanding what the internet is. One of the problems with medicine is that medical schools attract people with questionable technical backgrounds. We need to be accepting more engineering, mathematics, and science undergrads, and fewer people who are great at memorizing biochemical pathways.

  • NotAnotherSkippy||

    It's a generational thing. Older docs who grew up with transcriptions and can barely type struggle. Newer docs don't have the same problems.

    That doesn't mean that EMR has been or will be a net benefit though, particularly given the problems of meshing together different systems through finicky portals.

  • Griffin3||

    My wife types 80 wpm, and doesn't even look at her fingers. And still she struggles. The problem isn't the doctors, the problem is most EHR systems are a thin-layer client layered over databases and gov't-required questionaires, versus anything having to do with workflow.

  • Ron||

    Only 11 percent of physicians said electronic health records improved their interactions with patients, while 60 percent said they "detracted from patient interaction," the Physicians Foundation noted in 2016."

    this is so true when i see my doctor these days he doesn't look at me he looks at his computer screen typing while I describe my problem. If I did that to my clients they'd walk out on me. No sense in walking out on the doctor since they all do that and there are no available doctors taking new patients within 50 miles

  • CatoTheChipper||

    The 48 minutes, I'm sure, doesn't include the time that the doctor spends typing stuff into his computer during a patient's office visit. It's 48 minutes in addition to that.

    I can't speak to others' experience, but my own is that electronic records requirement has changed the doctor-patient relationship. Whereas, in the past I would speak face-to-face with a doctor during an office visit, now doctors are too busy looking at their computer and typing input to look at their patient.

  • swampwiz||

    My PCP types the info into the computer in the exam room during our visit. It's great.

  • GoatOnABoat||

    Ha ha ha "Affordable Care Act". War is peace. Freedom is slavery. More laws to make healthcare more affordable.

  • sharmota4zeb||

    After the passage of the Affordable Care Act, America's life expectancy when down for the first time in a very long time.

  • CatoTheChipper||

    Pelosi was proud that ACA created the right to health care.

    By "right to health care", she actually meant that the ACA created the duty to buy insurance at grossly inflated prices.

    It's funny how progressives confuse rights and duties.

  • swampwiz||

    But yet you're against her reforming the system to get the costs down via Medicare-For-All.

  • Bart DePalma||

    There is another major factor at work currently running under the radar.

    Both government and private health insurers are moving towards a modified HMO system paying doctors flat fees for various treatments. This shifts the risk of high cost patients and the subsequent care rationing decisions from the insurer to the doctor. Only a large practice or alliance of practices can absorb this risk.

  • JFree||

    That actually is what insurance SHOULD be. It is hospitals or larger-group practices who should be incurring outlier risk - NOT individuals. And for them, reinsurance (and yes at the govt level) would be the way they share that tertiary-care risk.

  • JunkScienceIsJunk||

    While I'm certainly against EHR government mandates, this sentence is misleading:

    "Using electronic records cost physicians an average extra 48 minutes per day, according to a 2014 report. "Surprisingly, a third (33.9%) reported that it took longer to find and review medical record data" with electronic records management than without it."

    We call this user error. Even bad EHRs (which I use every day...) are highly functional, are far more reliable aggregators than paper docs, facilitate communication, facilitate quality assurance and reporting, and reduce expenditures in large settings (automation -- duh).

    The problem, which the article circles around, is that small businesses can't afford this expense. But this isn't because the EHR is hard to use. It's because EHR is priced out of the market. And THIS is the other problem with the mandates... your EHR has to be one of the "approved" ones because too much is blamed on computers. For example, my hospital turned away a highly competitive information system because the startup company that created it could not afford the $10M in liability insurance in their pricing model that the hospital required of them. Instead, we paid 800% more for an EHR from an established company. This sort of shit is a practically insurmountable barrier to entry, and exacerbates the high cost of health care.

  • Ben of Houston||

    Sorry, but don't call user error when it's designer error. For primary care physicians, the things are a nightmare. They are good for certain people: some specialists, billing personnel, and administrators. However, as they were designed for the primary purpose of administration and billing, the actual patient is left as a secondary concern.

    I would suggest going onto any AMA forum and ask about EMRs. You will find a host of angry people who complain that charting is longer and more time consuming than ever. Ask any retiree and you will find complaints about how they wanted to treat the patient, not the chart. Perhaps your hospital has implemented one that works, but in my experience, the front line doctors are the ones who suffer and the billing department benefits.

  • JunkScienceIsJunk||

    I don't have to go into an AMA forum. I work closely with the CMIO of a large hospital on... you guessed it... EHR. You're absolutely right that a lot of physicians (probably even most) don't like it. But there is a subset of physicians who DO like it. When you probe more deeply and try to figure out the ones who think it's useful, it turns out to be the ones who are computer literate. Guess which ones hate it the most.

    That's not to say that all EHR systems are flawless. Even Epic has its detractors, let alone the "lesser" ones. But to suggest that it's not a net positive is ridiculous.

  • turco||

    We can argue till the cows come home whether EHR are good or bad. Bottom line adoption by doctors was slow until mandated by the govt. Ergo, EHRs were a failure in the market and were not ready for prime time.

    The main reason EHRs were pushed on doctors is to allow administrators to gather data and impose new regulations. The idea is that more data enables the top men to come up with better regulations.

  • JunkScienceIsJunk||

    Ergo, EHRs were a failure in the market and were not ready for prime time.

    As I argued above, you can't necessarily conclude that their market failure was because they weren't useful. As I said, the pricing for a complete implementation is absurdly high. The high revenue hospitals and academic medical centers in particular were early adopters and were unaffected by the mandate*. This wasn't a coincidence.

    * = this isn't entirely true... there's a lot of EHR-related shit that went along with ACA that even high revenue places weren't always adopting until the mandate -- synoptic reporting for example. But relatively speaking, this is a minor point.

  • Ron||

    its just another step in forcing everyone into the mega cities so they can receive medical care in order to protect the wilderness from mankind.

  • sharmota4zeb||

    +1

  • Cloudbuster||

    Many different electronic health records systems can't even speak to one another,

    You say that like its a bad thing. If incompetence and lack of interconnectivity is the only thing giving me a shred of health care privacy, I'm all for incompetence and lack of interconnectivity.

  • sharmota4zeb||

    Dude, the communication between experts is so fractured that a psych patient could slip through the cracks so long that by the time any licensed professional notices everyone is afraid to tell the judge for fear of having to explain how it happened. ;)

  • Echospinner||

    The lack of connection is intentional. Hospitals and health care systems are in competitive environments.

    The downside is that when the information needs to get there quickly, say you show up in the ER, it is not there if your last visit was outside that system. This results in unnecessary duplication for diagnostic tests and lack of critical information when it is needed.

  • Cloudbuster||

    Was discussing the ACA with a friend the other day. We are irreconcilably on opposing sides of the issue:

    1. I am a healthy, high-earning family man who has worked hard, invested wisely and pays a ton in taxes. I am leaving my corporate job soon, and the insurance that goes with it. All I want is a reasonable major medical policy, which the ACA makes impossible. I don't need office visit co-pays. I can pay for all planned expenses out-of-pocket. That's the way it should be.

    2. He lives off a trust fund, has never worked a day in his life, and has diabetes and MS which require continuing drug treatments that exceed $8,000 monthly.

    I make. He takes. I don't see how a meeting of minds his possible. His life depends on the idea that it is other peoples' responsibility to pony up $100k per year or so to keep him breathing and he's totally willing to use government force to achieve that.

  • sharmota4zeb||

    Homelessness is deadly, but here is no mandate for housing insurance. Politicians will spend a fortune in taxes on doctors, because doctors have fancy degrees from teachers who say that they know how to cure everything from bed bugs to anxiety. They are reluctant to spend on construction workers to provide the shelter that can prevent those problems at a fraction of the cost. Home builders don't get educated for the careers at the types of institutions that flatter politicians or advance their political philosophy.

  • JunkScienceIsJunk||

    I'm having a hard time understanding your analogy. Isn't housing assistance (projects, section 8, HUD, etc) more or less the same general concept as medicaid?

  • Echospinner||

    The most expensive population is the Medicare gap if you are buying insurance. People between around 55-65 years old.

    I am in that age. Anything you can buy in the Obamacare market is ridiculously expensive and I have. You pay different amounts based on age not medical history. It is also an age group where getting long term employment becomes more difficult.

    What we are talking about is risk stratification based on medical history which Obamacare rules do not allow.

    Not that hard to figure out why. The person with known type 1 diabetes and MS at age 30 is much higher risk than a 56 year old with no known major condition. Obamacare to some extent tried to bridge that. It has not worked as well as advertised nor has it failed as much as predicted.

  • JunkScienceIsJunk||

    He sat around too long that MS was the result? Have some compassion dude. I mean, you can oppose government force all you want, but to imply that not getting treatment is a desirable end for those who can't afford it is pretty callous. Libertarians should (and do) suggest there are alternatives to government force -- they don't say fuck 'em.

  • sharmota4zeb||

    Some people are brilliant enough to provide valuable services without needing the help of specialists. Others have the social skills to be part of a team that produces valuable services. And then there are doctors.

  • Echospinner||

    One thing not mentioned is that dictated reports in EMR now use voice recognition technology rather than being typed in by actual transcriptionists with a brain. VR makes many errors (often referred to as Dragon errors after the popular program). These are often missed as self editing is something of an oxymoron. Sometimes this produces garbled or misleading statements such as substituting "normal" for "abnormal".

    The tradeoff is that the information is there in minutes rather than hours which is a very good thing. The change is inevitable and also driven by cost considerations as the program is much cheaper than hiring transcriptionists. The extra effort and time spent is just shifted to the doctor who is not paid hourly.

    While docs can compensate to some extent by reading reports, say a radiology report or operative note alert to the possibility that there may be VR errors, there is without a doubt increased liability. Another burden shifted to the doctor.

  • Echospinner||

    One more thing.

    Moving to employment has some benefits for physicians. There tends to be better lifestyle like regular vacation, time off, better on call schedules, fewer administrative headaches and so on.

    There are negative consequences for patients and doctors in employment as opposed to solo or small group practice . Employment for docs is based on productivity. You can't just decide to slow down and take fewer patients per hour in order to spend more time with each one. The hospital or health care system also tracks how many billable procedures you perform and tests ordered with predictable consequences.

  • Ed in North Texas||

    I'm probably far from the average person, but I find that the inability of the various records systems to communicate with each other to be a feature, not a problem. If we have to have a system of medical records which hackers can penetrate, at least we can have a system where the records aren't easily assembled into a complete record for everyone. There is little doubt that there is no such thing as a system which is externally accessible, at least without TS-SCI level encription, which is hacker proof.

    As for physicians who do not spend great amounts of time recording patient data, I have at least one who does not. A dermatologist, he employs a recorder to accompany him and record his comments directly to the laptop.

  • ThomasD||

    The commoditization of everything. Smart people saw it coming decades ago.

    Your wife can quibble over the particulars of her profession, but everyone is dealing with it.

  • gee||

    You can thank Obama care...the affordable healthcare insurance that you can keep your doctor and afford.
    Lying sack of whale shit! Typical Democrat BS... Who says things like 'we have to pass it to see what's in it?'
    Our moron representatives....

  • DrZ||

    "But don't look for policymakers to admit that their vision for how the world should work might not play out properly in real life. If they were inclined to concede that people might be better off when left alone to arrange their own affairs, they probably wouldn't be policymakers."

    This is blatantly false. The average person would have never guessed in a million years that plastic soda straws are dangerous to society and wildlife. It took policymakers to force us into this realization. People are pretty stupid. Policy makers are bright and know more than you know. That's why they are policymakers instead of say, used car salesmen.

  • swampwiz||

    Oh, so a physician is complaining that she is no longer part of the bourgeoisie, and must now be a member of the proletariat? CROCODILE TEARS!

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